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Event Notification Report for January 6, 2010

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Event Reports For
01/05/2010 - 01/06/2010

** EVENT NUMBERS **


45602

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Other Nuclear Material Event Number: 45602
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: RICHARD L. ROUDEBUSH VA MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: PETE SNYDER
Notification Date: 12/31/2009
Notification Time: 12:18 [ET]
Event Date: 12/30/2009
Event Time: [EST]
Last Update Date: 12/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHN GIESSNER (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

UNDERDOSE TO PATIENT

The Richard L. Roudebush VA Medical Center holds VHA Permit Number 13-00694-03 under the VA's Master Material License (NRC License Number 03-23853-01VA).

"For a patient treatment on December 30, 2009, involving Yttrium-90 microspheres, the medical center discovered (on same date) that the total activity delivered to the treatment site was less than 80% of the total activity documented in the written directive.

"The medical event was discovered when a waste container, which contained used catheters, lines, gloves, tongs, tape, etc., from the treatment were assayed. The waste materials indicated a higher than expected residual activity equal to about 25 percent of the activity that was in the source vial prior to treatment. Examination of the waste materials revealed that nearly all of the residual activity was distributed somewhat uniformly along the length of the approximately 100 cm microcatheter tubing.

"The current estimate is that about 47.03 millicuries were delivered to the patient, and 15.67 millicuries were in the wastes. The prescribed activity was 63.2 millicuries. Therefore, the patient was under-dosed by about 25.6%. Because this deviation exceeds 20%, a medical event is considered to have occurred per 10 CFR 35.3045(a)(1).

"Although a lower-than-intended activity was administered, the permittee estimates that the absorbed dose to the target organ was around 109 gray and was within the therapeutic target range of 100 to 150 gray. Therefore, no adverse biological effects to the patient are expected."

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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